The nurse is preparing to speak to the facility’s social worker about the client’s condition. Select the 5 findings the nurse should plan to include in the report.
Client’s report of lack of access to bank accounts
Client’s avoidance of eye contact
Client’s report of weight loss
Numerous bruises in various stages of healing
Client’s report of lack of food in the house
Client’s strong body odor
Right arm fracture
Correct Answer : A,D,E,F,G
The nurse should plan to include the following five findings in the report to the social worker, as they raise significant concern for elder maltreatment:
Findings to Include
• A. Client’s report of lack of access to bank accounts → Suggests financial exploitation, especially since the client gives income to the adult child but cannot access funds.
• D. Numerous bruises in various stages of healing → Strong indicator of physical maltreatment, possibly repeated trauma over time.
• E. Client’s report of lack of food in the house → Points to neglect, particularly in meeting basic nutritional needs.
• F. Client’s strong body odor → Suggests neglect in hygiene and personal care.
• G. Right arm fracture → A confirmed injury that, in context with other findings, may not align with a simple accidental fall.
Findings Not Prioritized for Reporting
• B. Client’s avoidance of eye contact → May reflect fear or discomfort, but is not specific enough to confirm maltreatment.
• C. Client’s report of weight loss → While potentially concerning, it wasn’t documented in the case and lacks supporting data like previous weight or timeframe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Applying petroleum jelly to the glans of the penis is an important step in the care of a newborn who has undergone a Gomco circumcision. This acts as a protective barrier to prevent the glans from sticking to the diaper, which can cause pain and disrupt the healing process. This is done with each diaper change for the first few days.
Choice B rationale
The yellow, sticky exudate that forms on the glans is a normal part of the healing process and is composed of fibrin and serum. Wiping it off can disrupt the healing tissue and increase the risk of bleeding and infection. The parent should be instructed to allow this exudate to fall off naturally.
Choice C rationale
Applying gentle pressure with a diaper is not an appropriate intervention. The area should be kept as free from pressure as possible to promote healing and reduce discomfort. Pressure could cause bleeding, pain, or damage to the delicate new tissue that is forming.
Choice D rationale
Alcohol is a harsh astringent that can cause significant pain and irritation to the sensitive, healing tissue of the glans. It can also dry out the skin, delaying the healing process. Only warm water should be used to clean the area during diaper changes. .
Correct Answer is D
Explanation
Choice A rationale
Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.
Choice B rationale
Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.
Choice C rationale
Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.
Choice D rationale
Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.
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